A cognitive model of recurrent nightmares

Nightmares are a prevalent mental disorder resulting in disturbed sleep, distress, and impairment in daily functioning. Elaborating on previous theoretical models for anxiety disorders, sleep disorders and dreaming, this study introduces a cognitive model of recurrent nightmares, the central element of which concerns representation of the nightmare’s repetitive storyline in the memory as a script. It is suggested that activation of this script during REM sleep results in a replay of the nightmare, and that activation occurs through perceived similarity between dream elements and the nightmare script. The model proposes a central role for cognitive processes in the persistence of nightmares over time. The success of cognitive-behavioural treatments is explained and clinical implications are discussed

Frontoparietal Connectivity and Hierarchical Structure of the Brain’s Functional Network during Sleep

Frontal and parietal regions are associated with some of the most complex cognitive functions, and several frontoparietal resting-state networks can be observed in wakefulness. We used functional magnetic resonance imaging data acquired in polysomnographically validated wakefulness, light sleep, and slow-wave sleep to examine the hierarchical structure of a low-frequency functional brain network, and to examine whether frontoparietal connectivity would disintegrate in sleep. Whole-brain analyses with hierarchical cluster analysis on predefined atlases were performed, as well as regression of inferior parietal lobules (IPL) seeds against all voxels in the brain, and an evaluation of the integrity of voxel time-courses in subcortical regions-of-interest. We observed that frontoparietal functional connectivity disintegrated in sleep stage 1 and was absent in deeper sleep stages. Slow-wave sleep was characterized by strong hierarchical clustering of local submodules. Frontoparietal connectivity between IPL and superior medial and right frontal gyrus was lower in sleep stages than in wakefulness. Moreover, thalamus voxels showed maintained integrity in sleep stage 1, making intrathalamic desynchronization an unlikely source of reduced thalamocortical connectivity in this sleep stage. Our data suggest a transition from a globally integrated functional brain network in wakefulness to a disintegrated network consisting of local submodules in slow-wave sleep, in which frontoparietal inter-modular nodes may play a role, possibly in combination with the thalamus

Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature?

Sleep disturbances are often viewed as a secondary symptom of post-traumatic stress disorder (PTSD), thought to resolve once PTSD has been treated. Specific screening, diagnosis and treatment of sleep disturbances is therefore not commonly conducted in trauma centres. However, recent evidence shows that this view and consequent practices are as much unhelpful as incorrect. Several sleep disorders-nightmares, insomnia, sleep apnoea and periodic limb movements-are highly prevalent in PTSD, and several studies found disturbed sleep to be a risk factor for the subsequent development of PTSD. Moreover, sleep disturbances are a frequent residual complaint after successful PTSD treatment: a finding that applies both to psychological and pharmacological treatment. In contrast, treatment focusing on sleep does alleviate both sleep disturbances and PTSD symptom severity. A growing body of evidence shows that disturbed sleep is more than a secondary symptom of PTSD-it seems to be a core feature. Sleep-focused treatment can be incorporated into any standard PTSD treatment, and PTSD research needs to start including validated sleep measurements in longitudinal epidemiologic and treatment outcome studies. Further clinical and research implications are discussed, and possible mechanisms for the role of disturbed (REM) sleep in PTSD are described

Lucid dreaming

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Expanding Self-Help Imagery Rehearsal Therapy for Nightmares With Sleep Hygiene and Lucid Dreaming: A Waiting-List Controlled Trial

Nightmares are a common disorder with serious consequences. Recently, the cognitive behavioral interventions Imagery Rehearsal Therapy (IRT) and exposure proved effective in a self-help format. The aim of the current study was to compare the following self-help formats to a waiting-list: IRT; IRT with sleep hygiene; and IRT with sleep hygiene and a lucid dreaming section. Two-hundred-seventy-eight participants were included and randomized into a condition. Follow-up measurements were 4, 16, and 42 weeks after baseline. Seventy-three participants filled out all questionnaires and 49 returned the nightmare diaries. Contrary to our expectations, the original IRT was more effective than the two other intervention conditions. Moreover, IRT was the only intervention that convincingly proved itself compared to the waiting-list condition. However, these data should be interpreted with caution due to the low power and high dropout. Yet it seems that in a self-help format, IRT and exposure (which was validated previously) are the treatments of choice for treating nightmares

Long-term treatment effects of imagery rehearsal therapy for nightmares in a population with diverse mental disorders

Nightmares are a common problem with debilitating consequences. Meta-analyses have revealed that imagery rehearsal therapy (IRT), in which the storyline of the recurring nightmare is changed, is the treatment of choice for nightmares. In a randomized clinical trial, we recently demonstrated that IRT was also effective in a population of patients with diverse mental disorders. In this trial, IRT showed moderate additional benefits over treatment as usual on nightmare distress, general psychopathology, and posttraumatic stress symptoms. In the current paper we report on the six- and nine month follow-up measurements of the IRT group of this trial. In the six- and nine-month follow-up the moderate improvements observed at post-treatment were sustained for all measures. This means that IRT has long-lasting effects, also in a sample with severe co-morbid psychopathology. IRT could be considered at an early stage in addition to the usual mental health treatment